Ezrin immunohistochemical expression in advanced soft tissue sarcoma biopsy specimens from patients treated in a phase II trial of dose-dense doxorubicin- and ifosfamide-based chemotherapy

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Background: Ezrin is a member of the ERM (ezrin, radixin, moesin) protein family and links F-actin to the cell membrane, and it is involved in regulating growth and metastatic behaviour of cancer cells. Ezrin expression is associated with tumor progression and metastasis in several cancers, including sarcomas. This study evaluated ezrin expression as a predictor of response to chemotherapy and as a prognostic factor in soft tissue sarcoma (STS) patients (pts) treated in a dose-dense schedule protocol. Methods: 21 chemotherapy-naïve pts diagnosed with high-grade STS, not candidates for a limb-sparing surgery, were enrolled in a prospective phase II study of a sequential and dose-dense regimen consisting of doxorubicin 30 mg/m2 d1–3 q2w and ifosfamide 2.5 g/m2 d1–5 q3w, 3 cycles each, with G-CSF support. Ezrin expression was analyzed by immunohistochemistry on slides from formalin-fixed, paraffin-embedded, primary tumor biopsy blocks, with the anti-ezrin antibody clone AB-1(3C12) (NeoMarkers). Cytoplasmic immunostaining in more than 10% of tumor cells was considered as positive. Ezrin expression was correlated with response rate, progression-free (PFS) and overall survival (OS). Results: Leiomyo-, synovial and sarcoma NOS were the most frequent subtypes (5 pts each). 13 out of 21 pts (62%) presented distant metastasis. Protocol was halted after 3 toxic deaths. Three pts achieved partial response (RR 14%). With a median follow-up of 11.7 mo, median PFS and OS were 8.9 and 20.1 mo, respectively. In univariate analysis, OS was higher for synovial sarcoma pts (not reached vs. 14.2 mo, HR 0.0, 95%CI 0.06–0.82, p=0.02), and for those aged 45 y or less (20.1 vs. 4.2 mo, HR 0.30, 95%CI 0.03–0.88, p=0.04). Ezrin expression was available for 20 pts: it was positive in 9 pts (45%) and negative in 11 pts (55%). Ezrin expression was not related to tumor response (p = 0.40), and no significant association was detected between ezrin expression and median PFS or OS. Conclusions: Expression of ezrin was not a useful marker to predict outcomes in STS pts treated with dose-dense doxorubicin- and ifosfamide-based chemotherapy.

No significant financial relationships to disclose.

Phase II prospective study of dose-dense doxorubucin and ifosfamide in high-grade, locally advanced or metastatic soft tissue sarcoma (STS) patients

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Background: High grade STS is expected to benefit from dose-dense doxorubicin/ifosfamide (doxo/ifo) sequential chemotherapy. This trial was designed using the two-stage Minimax design, in which 6 responses were needed among the first 19 pts to proceed to the second stage of the trial (a=0.05, β=0.20) to detect a 20% difference in RR as compared to expected 30%. Preliminary results of the first 20 pts are presented. Patients and Methods: Eligible pts had untreated, metastatic or locally advanced, high-grade STS, > 5 cm; age 18- 60 y; ECOG-PS 0–2; normal cardiac, renal and hepatic function; and signed informed consent. Pts were treated with doxo 30 mg/m2/d, D1–3, every 14 d, 3 cycles, followed by ifo 2.5 g/m2/d, D1–5, every 21 d, 3 cycles, with mesna and G-CSF support. Results: 20 pts were enrolled (7 in the neo-adjuvant setting with curative intent, 13 palliative). Median age: 39y (23–60); 5 synovial, 5 leiomyo, 4 sarcoma NOS, 2 MFH, 4 others. Primary site: 11 lower extremity; mean tumor size 13 cm. Median number of cycles was 3 for both drugs. 12 pts completed all planned chemotherapy cycles, and the mean relative dose intensity was 92±15% and 89±16% for doxo and ifo, respectively. Anemia was the most frequent toxicity (18 pts). 75 cycles were administered and grade 3/4 toxicities (CTC NCI 2.0) were observed in 27. G3 neutropenia was observed in 4 pts, none fatal. Thromboembolic events occurred in 4 pts (2 DVT, 2 PE). One pt presented a LVEF drop from 60% to 34% and developed symptomatic cardiac failure. Among 10 evaluable pts who completed chemotherapy, no response (CR or PR) was observed; eight pts had stable and 2 progressive disease. Surgery was performed in 6 pts, 4 of them limb-sparing, without changing the previous surgical plan. None of these pts presented complete pathologic response, with rate of necrosis ranging from 0–60%. At a median follow-up of 6 mo (1–16), 6 pts had died: 4 of disease progression, one sudden death (unknown cause) after 2 wks from the last chemotherapy cycle, and one patient died from pulmonary embolism. Conclusion: Sequential high-dose doxorubicin followed by ifosfamide failed in demonstrating any response in high grade STS, in addition to an unacceptable toxicity profile. Results of overall survival are pending.

No significant financial relationships to disclose.

Morphological diagnosis of HPV lesions and cervical intraepithelial neoplasia (CIN) is highly reproducible

PURPOSE

to assess the value of individual histological criteria in the diagnosis of cervical HPV lesions.

METHODS

138 women referred for colposcopic evaluation (due to abnormal PAP smears) were subjected to cervical punch biopsy. The biopsies were classified as no HPV lesion, CIN 1, or CIN 2-3 by two observers independently. Kappa tests were used for interobserver agreement of the diagnosis. The presence of binucleation, multinucleation, abnormal mitosis. koilocytosis, spindle koilocytosis and dyskeratosis was similarly assessed.

RESULTS

the Kappa statistic was 0.638 (CI 95% 0.533-0.743), showing substantial inter-observer agreement. Abnormal mitosis and multi-nucleation were the two most powerful discriminators between CIN 2-3 and CIN 1. Koilocytosis proved to be the single most powerful discriminator between CIN 1 lesions and non-HPV lesions.

CONCLUSION

the results advocate the use of histology as the gold standard in diagnosing cervical precancerous lesions. The classical criteria can be also used to differentiate low-grade lesions, which has practical implications by avoiding the unnecessary treatment of minor abnormalities.

Cigarette smoking and high-risk HPV DNA as predisposing factors for high-grade cervical intraepithelial neoplasia (CIN) in young Brazilian women

BACKGROUND

This cross-sectional study was designed to evaluate the role of cigarette smoking and high-risk HPV types as risk factors of CIN 2 and 3 in young, sexually active Brazilian women.

MATERIALS AND METHOD

A series of 100 consecutive women with abnormal Pap smears were recruited, subjected to colposcopy, punch biopsy, and questionnaire for their social, sexual and reproductive factors. Of these, 77 women between 20 and 35 years of age (median 26.5 years) with biopsy-confirmed CIN 1 or CIN 2 and 3, were enrolled in this study. Representative samples from the exocervix and endocervix were obtained for HPV testing with the Hybrid Capture HPV-DNA assay, including the probes for the oncogenic HPV types (16, 18, 31, 33, 35, 45, 51, 52 and 56).

RESULTS

The overall rate of CIN 2 and 3 was 23/77 (29.8%). The women with CIN 1, 2 and 3 did not differ from each other with regard to their age, race, schooling, marital status, lifetime number of sexual partners, age at first intercourse, use of oral contraceptives, or parity. However, current cigarette smoking was strongly associated with CIN 2 and 3 (p<0.001), and among smokers, the risk of high-grade CIN increased in parallel with the time of exposure (years of smoking) (p=0.07). HPV-DNA of the oncogenic types was detected in 43 (56%) women, the risk of being HPV DNA-positive was significantly higher in CIN 2 and 3 as compared with CIN 1 (p=0.037). Importantly, the prevalence of high-risk HPV types was significantly higher in cigarette smokers than in non-smokers (p=0.046).

CONCLUSIONS

The results indicate that the severity of CIN lesions was clearly related to two fundamental risk factors: 1) high-risk HPV types, and 2) current cigarette smoking. These two risk factors were closely interrelated in that the high-risk HPV types were significantly more frequent in current smokers than in non-smokers, suggesting the possibility of a synergistic action between these two risk factors in cervical carcinogenesis.

Abdominal mycobacterial infection in acquired immunodeficiency syndrome patients

The authors studied 12 patients with AIDS and abdominal mycobacteriosis hospitalized in the Hospital Ipiranga (São Paulo, Brazil), from June 1989 to January 1992. Diagnosis was confirmed by the histopathological examination of organ specimens collected during laparotomy, which, in most cases, was carried out due to an emergency situation. Observations included perforation of the ileum, seropurulent fluid involved and bloked by viscera, epiploon, and fibrin. Hepatoesplenomegaly was present in all patients and generalized granulomatous peritonitis was observed in more than 50%. A patient died in the immediate post-op period, four after an average period of 55 days in the hospital. A patient evolved with stercoral fistula and asked to be discharged. Six patients were discharged after an average hospitalization period of 27 days. The authors stress that in developing regions where tuberculosis incidence is high, a patient with AIDS and a painful and irritative abdominal picture should always lead to the hypothesis of mycobacteriosis.

Modelo alternativo para o controle da esquistossomose: estado atual do projeto no Estado do Espírito Santo, Brasil

O trabalho que vem sendo desenvolvido em uma área rural do município de Afonso Cláudio (Espírito Santo) representa uma proposta alternativa aos atuais programas de controle. Este é um trabalho de pesquisa controlado, em integração interdisciplinar e multi-institucional, envolvendo várias entidades de pesquisa e de serviços. O modelo alternativo de controle da endemia conta com amplo envolvimento comunitário e com a organização dos serviços locais de saúde a nível primário (SUS). A pesquisa participante tem sido o ponto de partida metodológico que baliza os procedimentos de coleta e análise de dados e os de intervenção na realidade local. Os métodos de controle estão limitados ao tratamento médico individualizado e à melhoria das condições de saneamento. Estes métodos estão, evidentemente, integrados às ações sociais acima descritas. O projeto está dividido em três fases: pré-controle, controle (intervenção) e avaliação final. No momento, o mesmo entra em sua fase de intervenção, com duração prevista de três anos.

Human fatal yellow fever. Immunohistochemical detection of viral antigens in the liver, kidney and heart

An immunohistochemical method to detect yellow fever antigen was developed using immune sera from rabbits and hamsters and hyperimmune ascitic fluid from mice. A search for the antigen was carried out in liver, kidney and heart in three fatal cases of yellow fever. In the liver it was present in the cytoplasm of hepatocytes, Councilman bodies and Kupffer cells. Yellow fever antigen was also detected in renal tubular epithelium and in groups of myocardial fibers. These findings suggest that viral replication occurs at sites other than the liver. Since yellow fever shares many features with other haemorrhagic fevers the use of immunohistochemistry can impart a significant improvement in the accuracy of its histopathological diagnosis.

[The importance of fixation in immunohistochemistry: distribution of vimentin and cytokeratins in samples fixed in alcohol and formol]

The fixation in ethanol or formalin for trypsin digestion in immunohistochemical detection of cytokeratins and vimentin was assessed in a case of ovarian cystadenofibrocarcinoma. Superior reactivity for both markers was achieved in ethanol-fixed sections, even in samples stocked up to 60 days. Cytokeratin reaction in formalin-fixed sections was better when trypsin was used. However, this digestion was deleterious to vimentin detection. These data are presented to alert surgeons and oncologists on the relevance of fixation of specimens suspicious for neoplasia, since different epitopes may require different fixatives and the inadequate choice in the operative room may impart difficulties when immunohistochemistry is necessary.

[Ileal loop perforation caused by tuberculosis in patients with the acquired immunodeficiency syndrome]

This clinical and surgical study was performed in a Public Government Hospital with the purpose of investigating the etiology and treatment of acute perforative abdomen in AIDS patients, particularly in the case of intestinal tuberculosis. The authors describe the cases of two young male AIDS patients with acute abdomen in which surgery revealed intestinal ileal perforation due to tuberculosis. One of the patients did not survive due to his poor post-operative condition. The other case had a better evolution and was submitted to outpatient care. The immediate surgery with occlusion of the perforation and biopsy of the lesion permitted to arrive at the etiology and contributed to the good evolution of the second patient.

CONCLUSION

Literature indicates cytomegalovirus as the main cause of intestinal perforation in AIDS patients. In this study, etiology was tuberculous and this is probably an important cause of acute perforative abdomen in our AIDS patients due to the general prevalence of tuberculosis in AIDS patients in Brazil and in other developing countries.